1. No category

Mentalization-Based Treatment, MBT
2014
• An innovative form of
psychodynamic psychotherapy
• Developed and manualised by
Peter Fonagy & Anthony Bateman
• Designed for individuals with BPD
• Improve
affect regulation
interpersonal relationships
MBT
MBT
• Introduces some concepts from cognitive
psychology, notable contingency theory
• Allied with developments in attachment
theory and associated research
• Discards some psychoanalytic tenets, such as
emphasis on revealing unconscious meaning
• Seeks links with neurophysiology
•
Gergely & Watson, 1999
Bateman AW et al
Int Rev Psychiatry 2007; 19:51-62
Mirroring the Affects of the Child
• . . . the precursor of the mirror is the mother‟s
face
Winnicott DW, 1971, p. 111
Problematic Mirroring
•
vs.
• If the mother‟s face is unresponsive, then a
mirror is a thing to be looked at but not
looked into
Winnicott DW, 1971, p. 113
www.dreamstime.com/mother-and-infant-looking-...
Common Factor in Psychotherapy
• Psychic structure is composed of
I. A representation of self
II. A representation of the other in relation to self
III. An affect linking the two
attachment, frustration, rejection
• All psychotherapies, whatever their focus,
share the potential to re-create an
interpersonal matrix of attachment in which
mentalization develops and sometimes
flourishes.
Bateman A & Fonagy P; 2012
Clarkin JF et al
J Personal Disord 2008; 21:474-9
Mentalizing
Attachment
https://www.enneagraminstitute.com/articles/NArtObRel.asp
Perceive the internal frame of reference
of another with accuracy and
with the emotional components &
meanings
Without ever losing the “as if” condition.
Carl Rogers, 1959
• The capacity to think & feel
oneself into the inner life of another
person.
Decety J, Jackson P
Behav Cogn Neurosci Rev 2004; 3:71-100
Heinz Kohut, 1984
Processes Involved in Empathy
• Identification
• Incorporation
• Reverberation
• Detachment
(a) an affective response
to another
person, which often, but not always, entails
sharing that person‟s emotional state;
(b) a cognitive capacity
to take the
perspective of the other person;
(c) some regulatory mechanisms
that
keep track of the origins of self and otherfeelings
: cognition and affect
: flexibility
Reik T, 1949
Holding & Containment
• Holding (I)
• Derives from Winnicott‟s (1965) notion that a
mother provides a specific form of
environment that facilitates an infant‟s
growth. Through interactions between a
mother and her infant, a shared transitional
space is created in which the infant ultimately
internalizes holding functions performed by
the mother.
Glen O. Gabbard, 1994
Holding & Containment
• Holding (II)
• ……the mother must not be too good. Only
through frustration and disillusionment can
the infant ultimately grows. ……therapist
must set limits in certain situations.
Glen O. Gabbard, 1994
Holding & Containment
• Holding (III)
• Holding also involves surviving. Winnicott
(1968) believed that the therapist‟s survival of
the borderline patient‟s destructive attacks is
crucial element in helping the patient to make
use of the therapist as a truly external object
outside the patient‟s omnipotent control.
Glen O. Gabbard, 1994
Holding & Containment
• Containment (I)
• Stems from Bion‟s (1984) description of how
the mother processes the affects of her baby.
The mother bears the uncontainable affects of
her baby, and through her reverie, she
detoxifies and transforms the affects into a
form that allows the infant to reintroject and
tolerate them.
•
Glen O. Gabbard, 1994
Holding & Containment
• Both Holding & Containing imply an
alternative to action—a postponement of
impulsive reaction to the patient in the
service of bearing and processing powerful
feelings generated in the patient-therapist
dyad.
Holding & Containment
• Containment (II)
• Containment should not be equated with a
kind of passive inaction (Rosenfeld, 1987)
• Nor should it be understood as
masochistically enduring the patient‟s
attacks (Ogden, 1982)
• Containment involves silent processing, but
it also entails verbal clarifications of what is
going on inside the patient and what is
transpiring in the patient-therapist dyad.
Gabbard GO, 1994
Attachment Figures
• Provide protection, promote safe exploration
of the environment and help the infant learn
to regulate emotions in a pro-adaptive,
effective way.
•
Gabbard GO, 1994
• To do nothing, to be with
Wolff HH, 1971
Hruby R, Hasto J, Minarik P
Neuro Endocrinol Lett 2011;32:111-20
Internal Working Model
Pairs of Attachment Style
•
Caregiver
•
Infant
Secure
Dismissing
Preoccupied
Secure
Avoidant
Ambivalent/Preoccupied
Disorganized/Unresolved
Disorganized/Unresolved
1996
Role reversal or aggressively directive & punitive
at 6 Y/O
http://www.thedigeratilife.com/blog/buy-cheapeyeglasses-online/
Change in Attachment
• Longitudinal studies showing about 20%
discontinuity over time
• Different attachment to different caregivers
• Change in attachment style over the course of
psychotherapy
• Change in couples attachment when an secure
person marries and insecure person
Process of Mentalization
psychic equivalence modes
pretend modes
reflective modes
Mentalizing
•
•
•
•
imaginative
perceiving
interpreting
intentional
Mentalizing
• Perceiving social and emotional cues
fusiform gyrus (identifying individuals, e.g., by face)
superior temporal sulcus (perceiving agency and intention)
temporal pole (interpreting social scenarios)
amygdala (detecting emotion, especially threat)
• Resonating emotionally
mirror neurons (activated by performing and observing
actions and by feeling and observing emotions)
• Mentalizing emotion and interpersonal interactions
medial prefrontal cortex
anterior cingulate cortex
mentalizing region”
The Neural Correlates of
Maternal & Romantic Love
• Both deactivated
a common set of
regions associated with negative emotions,
social judgment and „mentalizing‟
’
’, that is, the assessment of
other people's intentions and emotions
Bartels A, Zeki S
Neuroimage 2004;21(3):1155-66
Effective Principles of Therapeutic Change
• A strong working alliance
• An empathic and flexible approach to repairing
ruptures to the alliance
• A therapist attitude of caring, warmth,
empathy, positive regard, congruence, and
authenticity
• Patient-therapist agreement on treatment goals
• Strong collaboration between patient and
therapist in working toward goals
• A relatively high level of therapist activity
Critchfield KL & Benjamin LS, 2006
Integration of therapeutic factors in treating personality disorders
Reflective Parenting &
Development of Mentalization
“
“
“
“
World Psychiatry 2010; 9:11-15
• The primary aim of any intervention has to be
to re-instate mentalizing when it is lost or to
help to maintain it in circumstances when it
might be lost or is being lost
• Any intervention that succeeds in these
aims may be used in MBT
Mechanisms of change in MBT
• A safe attachment context
safe to explore the mind of the other
• Encourage to
mentalize
experience and confront negative affect
elaborate and review issues of morality＊
＊ from the Latin moralitas "manner,
character, proper behavior"
http://www.tc-of.org.uk/index.php?title=Recent_PD/Non-TC_Cartoons
Birth of the Agentive Self
Psychological self
?”
?”
• Having the person in mind.
• Bridge the focus on physical reality &
internally directed attention.
Fonagy P, Target M
Dev Psychopathol 1997; 9:679-700
Subjectivity
Bateman & Fonagy, 2004
Mentalized Affectivity
Elements of mentalized affectivity
I. Identifying
II. Modulating
III. Expressing
Development of Self
Some Features of Successful Mentalizing
of People & Relationships
• Curiosity
• Stance of safe uncertainty/opaqueness of
mental states
• Reflective contemplation
• Perspective taking
• Forgiveness
• Impact awareness
Mirroring
Idealizing
Twinship
Bateman A & Fonagy P, 2012
Some Features of Successful Mentalizing
of People & Relationships
•
•
•
•
•
•
A trusting attitude
Humility(moderation)
Playfulness & (self-mocking) humor
Willingness to take turns
A belief in changeability
A willingness to assume responsibility &
accept accountability
Bateman A & Fonagy P, 2012
Techniques for Mentalizing the Moment
•
•
•
•
•
•
•
•
•
•
Simmering down
Disentangling feeling states
Marking
Individual resonating
“Colombo”-style curiosity
Searching for positives
Mini role-plays: experimenting & rehearsing
Enacting problem scenarios
Weighing pros & cons
Subtitling
Bateman A & Fonagy P, 2012